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A study of admissions and inpatients over the Christmas period using the appropriateness evaluation protocol (AEP)
Archives of Gerontology and Geriatrics 31 (2000) 77 – 83 www.elsevier.com/locate/archger
A study of admissions and inpatients over the Christmas period using the appropriateness evaluation protocol (AEP) David J.E. Henshawa,*, Lucy M. Pollockb, Gurcharan S. Raic, Timothy A. Gluckd a b
Geriatric Department, St Andrews Hospital, De6as St, Bow, London E3 3NT, UK Taunton and Somerset Hospital, Musgro6e Park, Taunton, Somerset TA1 5DA, UK c Whittington Hospital, Highgate Hill, London N19 5NF, UK d Barnet General Hospital, Wellhouse Lane, Barnet, EN5 3DJ, UK.
Received 31 January 2000; received in revised form 6 June 2000; accepted 7 June 2000
Abstract The aim of the study was to examine appropriateness of admissions and inpatients over Christmas especially in the elderly. The study was a prospective audit of admissions and inpatients to the Whittington Hospital. The main outcome measures were appropriateness of admission or day of hospital residence using the Appropriateness Evaluation Protocol. The protocol was applied to admissions and inpatients over Christmas and control periods. The results showed that there was a significant difference in the number of elderly admissions between the control period and Christmas period, 94 (34%) vs. 104 (43%) (P = 0.02). However there was no corresponding change in appropriateness of elderly admissions, ten (10.6%) vs. six (5.8%), (P=0.2). The inappropriateness of day of hospital residence increased from 10% on the control day to 20% on the study day (P= 0.02). In conclusion elderly patients are not admitted more inappropriately over Christmas but their discharge at this time appears to be delayed resulting in inappropriate bed use. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Christmas admissions; Appropriateness of admission; Bed use; Health care evaluation mechanisms
* Corresponding author. Present address: 20a Harpenden Rise, Harpenden Herts AL5 3BH UK. Tel.: + 44 20747640000. E-mail address: [email protected] (D.J.E. Henshaw). 0167-4943/00/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S0167-4943(00)00069-8
78
D.J.E. Henshaw et al. / Arch. Gerontol. Geriatr. 31 (2000) 77–83
1. Introduction Hospital bed crises tend to occur in the winter months especially over Christmas and New Year. A possible explanation is that the beds fill up with medically inappropriate admissions. The term ‘Granny-Dumping’ has been coined to describe elderly people admitted for non-medical reasons when the relatives or carers want to avoid looking after them (Tanne, 1992; Random House Webster’s College Dictionary, 1996). An audit of a geriatric assessment unit in Scotland suggested a rise in admissions from 6% pre-Christmas to 15% over Christmas due to a breakdown in social services (Murdoch, 1996). However no published work describes formal assessment associated with admission criteria. The other contributing factor to the belief that ‘Granny dumping’ occurs may be that elderly people remain in hospital longer than medical treatment requires and thus their continued stay is inappropriate. Our study aimed to assess primarily the appropriateness of medical admissions over the holiday period and to compare younger and older patients. The study also aimed to look at the appropriateness of bed use during the holiday period by both younger and older inpatients. We used the Appropriateness Evaluation Protocol (AEP) (Gertman and Restuccia, 1981), a score that has been widely validated and has been recommended as a tool for audit of acute medical admissions by the Royal College of Physicians (Houghton and Hopkins, 1996). The criteria are split into two groups — appropriateness of admission and appropriateness of hospital residence (‘day of care’) on a sample day. The criteria for each group are shown below. For an admission to be appropriate or for an inpatient’s hospital residence to be appropriate only one of the criteria has to be fulfilled. The protocol also deals with those patients who do not fulfil the criteria. These patients are reviewed and a consensus decision is made as to whether the admission or hospital residence is appropriate. We have used it in accordance with the guidelines from the Royal College of Physicians and the European Union Biomed project for hospital utilisation review (Liberati et al., 1995) and in this case the score identified groups of patients in hospital for clearly non-medical reasons.
2. Patients and methods The primary outcome measure, appropriateness of admission, was assessed by studying consecutive acute medical admissions over two periods of a fortnight. The control period was 22 November 1995–6 December 1995, and the study period was 20 December 1995 – 3 January 1996, to encompass Christmas and New Year holidays. To study the appropriateness of hospital residence, all medical inpatients on 7 December 1996 (as a control day) and 28 December 1996 (as the study day) were examined. The control days were chosen so as to be close temporally to the study days without being within the holiday period. There were no extreme weather conditions on any of the days studied. All studies took place at the Whittington
D.J.E. Henshaw et al. / Arch. Gerontol. Geriatr. 31 (2000) 77–83
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Hospital (a London teaching hospital). There was no prior publicity of the study’s taking place. The investigators assessed each patient from medical and nursing notes, using the applicable criteria of AEP. If patients were inappropriate by AEP criteria then reasons for their admission or stay were documented and classified as described in the original design of the protocol.
2.1. Appropriateness e6aluation protocol appropriateness of admission criteria 2.1.1. (a) Se6erity of illness criteria 1. Sudden onset of unconsciousness or disorientation. 2. Pulse rate (a) B 50 or (b) \ 140 per min. 3. Blood pressure (a) systolic B90 or \ 200 mmHg or (b) diastolic B 60 or \ 120 mmHg. 4. Acute loss of sight or hearing. 5. Acute loss of ability to move body part. 6. Persistent fever: \37.8 C orally or 38.3 C rectally for \ 5 days. 7. Active bleeding. 8. Severe electrolyte imbalance: (a) Na B 123 or \ 156 mmol/l; (b) K B 2.5 or \6 mmol/l: (c) venous bicarbonate B 20 or \ 36 mmol/l (unless chronically abnormal): (d) arterial pH B7.30 or \7.45. 9. ECG evidence of acute ischaemia. 10. Wound dehiscence or evisceration. 2.1.2. (b) Intensity of ser6ice criteria 11. Intravenous medication and/or fluid replacement. 12. Surgery or procedure scheduled within 24 h requiring (a) general or regional anaesthesia or (b) use of equipment, facilities or procedure available only in a hospital. 13. Vital sign monitoring every 2 h or more often. 14. Chemotherapeutic agents that require continuous observation for potential life threatening toxic reaction. 15. Intramuscular antibiotics at least every 8 h. 16. Intermittent or continuous respirator use every 8 h. 2.2. Appropriateness e6aluation protocol day of care criteria 2.2.1. (a) Medical ser6ices 1. Procedure in operating theatre that day. 2. Scheduled for procedure in operating theatre the next day, requiring preoperative consultation or evaluation. 3. Cardiac catheterisation that day. 4. Angiography that day. 5. Biopsy of internal organ that day. 6. Thoracocentesis or paracentesis that day.
D.J.E. Henshaw et al. / Arch. Gerontol. Geriatr. 31 (2000) 77–83
80
7. Invasive central nervous system procedure that day. 8. Any test requiring strict dietary control. 9. New or experimental therapy requiring frequent dose adjustments under medical supervision. 10. Close medical monitoring by a doctor at least three times daily (documented in notes). 11. Postoperative day covered in 1 or 3–7 above.
2.2.2. 12. 13. 14. 15. 16. 17. 18.
(b) Nursing/life support ser6ices Respiratory care at least three times daily. Parenteral therapy. Continuous vital sign monitoring, at least every 30 min for at least 4 h. Intramuscular or subcutaneous injections at least twice daily. Intake and output measurement. Major surgical wound and drainage care. Close medical monitoring by a nurse at least three times daily.
2.2.3. (c) Patient’s condition Within 24 h. 19. Inability to void bowels not attributable to any neurological condition. Within 48 h. 20. Transfusion due to blood loss. 21. Ventricular fibrillation or ECG evidence of acute ischaemia. 22. Fever \ 37.8 C orally or 38.3 rectally if patient admitted for reason other than fever. 23. Coma for at least 1 h. 24. Acute confusional state not due to alcohol withdrawal. 25. Acute haematological disorders yielding symptoms or signs. 26. Progressive acute neurological difficulties. 27. Occurrence of a documented acute MI or stroke within 2 weeks. 2.3. Statistical analysis Data was analysed using chi-squared analysis with Yates correction and statistical significance was measured by applying a 95% level of confidence (PB0.05).
3. Results In the first part of the study (appropriateness of admission) 277 patients were admitted in the control period and 240 in the study period. In the appropriateness of hospital residence study 223 inpatients and 237 inpatients were reviewed in the control and study periods respectively. Both parts had a 90% power to detect an increase of 15% in medically inappropriate patients. The results are shown in Tables 1 and 2.
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In the first section of the study three of the investigators were admitting registrars. The investigators were not significantly different in their rate of inappropriate admissions than non-investigators (P= 0.86). In the second section of the study the assessments were completed by the same three investigators and an inter-observer reliability check on 22 patients showed 95% reliability. At that time, none of the assessors worked at the Whittington.
3.1. Appropriateness of admission The results are shown in Table 1. There was a significant difference in the number of elderly admissions 94 (34% of admissions) in the control period compared to 104 (43% of admissions) in the study period (P=0.03). There was no significant difference in the number of inappropriate admissions in the elderly, ten (10.6%) in the control period and six (5.8%) in the study period (P= 0.2). Thus it appears that although there was a greater proportion of elderly admissions in the Christmas period there was no corresponding increase in inappropriateness.
3.2. Appropriateness of residence The results are shown in Table 2. The increase in inappropriate bed use in the elderly from 10 to 20% was statistically significant (P= 0.02). There was no difference in inappropriate bed use in the younger population. The patients who were deemed inappropriate were classified into various groups. These results are shown in Table 3.
4. Discussion The inappropriateness rates found in our study are similar to those in other studies using the AEP. The most comparable paper described 186 consecutive Table 1 Appropriateness evaluation protocol (AEP) results for admissions studied 75 years and younger
76 years and older
Control period Inappropriate Appropriate Total
8 (1)a 175 (29) 183 (30)
4.4%b 95.6% 100%
10 (4) 84 (20) 94 (24)
10.6% 89.4% 100%%
Study period Inappropriate Appropriate Total
6 (2) 130 (44) 136 (46)
4.4% 95.6% 100%
6 (1) 98 (30) 104 (31)
5.8% 94.2% 100%
a b
Numbers in parentheses are those admitted by investigators. Percentages are of the total for that age group and that time period.
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Table 2 Results of the appropriateness evaluation protocol (AEP) day of care criteria 75 years and younger
76 years and older
Control period Inappropriate Appropriate Total
9 104 113
8%a 92% 100%
11 99 110
10% 90% 100%
Study period Inappropriate Appropriate Total
8 88 96
8% 92% 100%
28 113 141
20% 80% 100%
a
Percentages are of the total for that age group and day.
Table 3 Patients who were found to be inappropriate for day of care. The table shows reasons for continued stay in hospitala
Awaiting assessment or discharge package home Awaiting placement in residential or nursing home Awaiting other speciality bed or opinion Discharge planned \3 days Other
Inappropriate 7 December 1996 (n =20)
Inappropriate 28 December 1996 (n =36)
7 (4)
11 (10)
7 (5)
7 (6)
3 (1) 0 3 (1)
9 (4) 3 (3) 6 (5)
a
The table shows reasons for continued stay in hospital. Number for patients 75 years old and over in parentheses.
elderly admissions in Portsmouth, UK (Tsang and Severs, 1995) that showed an inappropriateness rate of 11% on AEP. We concur with Tsang and Severs that 100% appropriateness is neither beneficial nor desirable as this would suggest that some patients who were appropriate for admission had been discharged home. Our study has shown that although there was an increased proportion of elderly admissions over the holiday period there was no increase in the proportion or numbers of inappropriate elderly admissions. The numbers of younger medical admissions over the Christmas period were less. This could reflect younger people travelling over the holiday period, reduced GP referrals, or random variation. The study suggests that there is not an increase in inappropriate admissions over the Christmas holiday period amongst the elderly. Previous studies (Houghton et al., 1996; Smith et al., 1997) in non-holiday periods have suggested that delayed discharge is more important than inappropriate admission. Our study suggests that there is a genuine increase in inappropriate bed use over the Christmas holiday period, and that this is largely accountable for by delays in planning and execution of discharge of the elderly over Christmas.
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Acknowledgements We would like to thank Prof. James Malone-Lee for his constructive criticism and thank the CREED department at the Whittington hospital for their help with data collection and analysis.
References Gertman, P.M., Restuccia, J.D., 1981. The appropriateness evaluation protocol: a technique for assessing unnecessary days of hospital care. Med. Care 19, 855 – 871. Houghton, A., Hopkins, A., 1996. Acute medical admissions: results of a national audit. J. R. Coll. Physicians Lond. 30, 551–559. Houghton, A., Bowling, A., Jones, I., Clarke, K., 1996. Appropriateness of admission and the last 24 hours of hospital care in medical wards in an east London teaching group hospital. Int. J. Qual. Health Care 8, 543–553. Liberati, A., Apolone, G., Lang, T., Lorenzo, S., 1995. A European project assessing the appropriateness of hospital utilization: background, objectives and preliminary results. The Project Steering Group and the Coordinating Center. Int. J. Qual. Health Care 7, 187 – 199. Murdoch, P.S., 1996. Out in the cold at Christmas. Hospital Doctor, 21. 1-1-1996. Random House Webster’s College Dictionary. 1996. Smith, H.E., Pryce, A., Carlisle, L., Jones, J.M., Scarpello, J., Pantin, C., 1997. Appropriateness of acute medical admissions and length of stay. J. R. Coll. Physicians Lond. 31, 527 – 532. Tanne, J.H., 1992. Granny dumping in the US [news]. Br. Med. F. 304, 333 – 334. Tsang, P., Severs, M.P., 1995. A study of appropriateness of acute geriatric admissions and an assessment of the Appropriateness Evaluation Protocol [see comments]. J. R. Coll. Physicians Lond. 29, 311–314.
.
A study of admissions and inpatients over the Christmas period using the appropriateness evaluation protocol (AEP) David J.E. Henshawa,*, Lucy M. Pollockb, Gurcharan S. Raic, Timothy A. Gluckd a b
Geriatric Department, St Andrews Hospital, De6as St, Bow, London E3 3NT, UK Taunton and Somerset Hospital, Musgro6e Park, Taunton, Somerset TA1 5DA, UK c Whittington Hospital, Highgate Hill, London N19 5NF, UK d Barnet General Hospital, Wellhouse Lane, Barnet, EN5 3DJ, UK.
Received 31 January 2000; received in revised form 6 June 2000; accepted 7 June 2000
Abstract The aim of the study was to examine appropriateness of admissions and inpatients over Christmas especially in the elderly. The study was a prospective audit of admissions and inpatients to the Whittington Hospital. The main outcome measures were appropriateness of admission or day of hospital residence using the Appropriateness Evaluation Protocol. The protocol was applied to admissions and inpatients over Christmas and control periods. The results showed that there was a significant difference in the number of elderly admissions between the control period and Christmas period, 94 (34%) vs. 104 (43%) (P = 0.02). However there was no corresponding change in appropriateness of elderly admissions, ten (10.6%) vs. six (5.8%), (P=0.2). The inappropriateness of day of hospital residence increased from 10% on the control day to 20% on the study day (P= 0.02). In conclusion elderly patients are not admitted more inappropriately over Christmas but their discharge at this time appears to be delayed resulting in inappropriate bed use. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Christmas admissions; Appropriateness of admission; Bed use; Health care evaluation mechanisms
* Corresponding author. Present address: 20a Harpenden Rise, Harpenden Herts AL5 3BH UK. Tel.: + 44 20747640000. E-mail address: [email protected] (D.J.E. Henshaw). 0167-4943/00/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S0167-4943(00)00069-8
78
D.J.E. Henshaw et al. / Arch. Gerontol. Geriatr. 31 (2000) 77–83
1. Introduction Hospital bed crises tend to occur in the winter months especially over Christmas and New Year. A possible explanation is that the beds fill up with medically inappropriate admissions. The term ‘Granny-Dumping’ has been coined to describe elderly people admitted for non-medical reasons when the relatives or carers want to avoid looking after them (Tanne, 1992; Random House Webster’s College Dictionary, 1996). An audit of a geriatric assessment unit in Scotland suggested a rise in admissions from 6% pre-Christmas to 15% over Christmas due to a breakdown in social services (Murdoch, 1996). However no published work describes formal assessment associated with admission criteria. The other contributing factor to the belief that ‘Granny dumping’ occurs may be that elderly people remain in hospital longer than medical treatment requires and thus their continued stay is inappropriate. Our study aimed to assess primarily the appropriateness of medical admissions over the holiday period and to compare younger and older patients. The study also aimed to look at the appropriateness of bed use during the holiday period by both younger and older inpatients. We used the Appropriateness Evaluation Protocol (AEP) (Gertman and Restuccia, 1981), a score that has been widely validated and has been recommended as a tool for audit of acute medical admissions by the Royal College of Physicians (Houghton and Hopkins, 1996). The criteria are split into two groups — appropriateness of admission and appropriateness of hospital residence (‘day of care’) on a sample day. The criteria for each group are shown below. For an admission to be appropriate or for an inpatient’s hospital residence to be appropriate only one of the criteria has to be fulfilled. The protocol also deals with those patients who do not fulfil the criteria. These patients are reviewed and a consensus decision is made as to whether the admission or hospital residence is appropriate. We have used it in accordance with the guidelines from the Royal College of Physicians and the European Union Biomed project for hospital utilisation review (Liberati et al., 1995) and in this case the score identified groups of patients in hospital for clearly non-medical reasons.
2. Patients and methods The primary outcome measure, appropriateness of admission, was assessed by studying consecutive acute medical admissions over two periods of a fortnight. The control period was 22 November 1995–6 December 1995, and the study period was 20 December 1995 – 3 January 1996, to encompass Christmas and New Year holidays. To study the appropriateness of hospital residence, all medical inpatients on 7 December 1996 (as a control day) and 28 December 1996 (as the study day) were examined. The control days were chosen so as to be close temporally to the study days without being within the holiday period. There were no extreme weather conditions on any of the days studied. All studies took place at the Whittington
D.J.E. Henshaw et al. / Arch. Gerontol. Geriatr. 31 (2000) 77–83
79
Hospital (a London teaching hospital). There was no prior publicity of the study’s taking place. The investigators assessed each patient from medical and nursing notes, using the applicable criteria of AEP. If patients were inappropriate by AEP criteria then reasons for their admission or stay were documented and classified as described in the original design of the protocol.
2.1. Appropriateness e6aluation protocol appropriateness of admission criteria 2.1.1. (a) Se6erity of illness criteria 1. Sudden onset of unconsciousness or disorientation. 2. Pulse rate (a) B 50 or (b) \ 140 per min. 3. Blood pressure (a) systolic B90 or \ 200 mmHg or (b) diastolic B 60 or \ 120 mmHg. 4. Acute loss of sight or hearing. 5. Acute loss of ability to move body part. 6. Persistent fever: \37.8 C orally or 38.3 C rectally for \ 5 days. 7. Active bleeding. 8. Severe electrolyte imbalance: (a) Na B 123 or \ 156 mmol/l; (b) K B 2.5 or \6 mmol/l: (c) venous bicarbonate B 20 or \ 36 mmol/l (unless chronically abnormal): (d) arterial pH B7.30 or \7.45. 9. ECG evidence of acute ischaemia. 10. Wound dehiscence or evisceration. 2.1.2. (b) Intensity of ser6ice criteria 11. Intravenous medication and/or fluid replacement. 12. Surgery or procedure scheduled within 24 h requiring (a) general or regional anaesthesia or (b) use of equipment, facilities or procedure available only in a hospital. 13. Vital sign monitoring every 2 h or more often. 14. Chemotherapeutic agents that require continuous observation for potential life threatening toxic reaction. 15. Intramuscular antibiotics at least every 8 h. 16. Intermittent or continuous respirator use every 8 h. 2.2. Appropriateness e6aluation protocol day of care criteria 2.2.1. (a) Medical ser6ices 1. Procedure in operating theatre that day. 2. Scheduled for procedure in operating theatre the next day, requiring preoperative consultation or evaluation. 3. Cardiac catheterisation that day. 4. Angiography that day. 5. Biopsy of internal organ that day. 6. Thoracocentesis or paracentesis that day.
D.J.E. Henshaw et al. / Arch. Gerontol. Geriatr. 31 (2000) 77–83
80
7. Invasive central nervous system procedure that day. 8. Any test requiring strict dietary control. 9. New or experimental therapy requiring frequent dose adjustments under medical supervision. 10. Close medical monitoring by a doctor at least three times daily (documented in notes). 11. Postoperative day covered in 1 or 3–7 above.
2.2.2. 12. 13. 14. 15. 16. 17. 18.
(b) Nursing/life support ser6ices Respiratory care at least three times daily. Parenteral therapy. Continuous vital sign monitoring, at least every 30 min for at least 4 h. Intramuscular or subcutaneous injections at least twice daily. Intake and output measurement. Major surgical wound and drainage care. Close medical monitoring by a nurse at least three times daily.
2.2.3. (c) Patient’s condition Within 24 h. 19. Inability to void bowels not attributable to any neurological condition. Within 48 h. 20. Transfusion due to blood loss. 21. Ventricular fibrillation or ECG evidence of acute ischaemia. 22. Fever \ 37.8 C orally or 38.3 rectally if patient admitted for reason other than fever. 23. Coma for at least 1 h. 24. Acute confusional state not due to alcohol withdrawal. 25. Acute haematological disorders yielding symptoms or signs. 26. Progressive acute neurological difficulties. 27. Occurrence of a documented acute MI or stroke within 2 weeks. 2.3. Statistical analysis Data was analysed using chi-squared analysis with Yates correction and statistical significance was measured by applying a 95% level of confidence (PB0.05).
3. Results In the first part of the study (appropriateness of admission) 277 patients were admitted in the control period and 240 in the study period. In the appropriateness of hospital residence study 223 inpatients and 237 inpatients were reviewed in the control and study periods respectively. Both parts had a 90% power to detect an increase of 15% in medically inappropriate patients. The results are shown in Tables 1 and 2.
D.J.E. Henshaw et al. / Arch. Gerontol. Geriatr. 31 (2000) 77–83
81
In the first section of the study three of the investigators were admitting registrars. The investigators were not significantly different in their rate of inappropriate admissions than non-investigators (P= 0.86). In the second section of the study the assessments were completed by the same three investigators and an inter-observer reliability check on 22 patients showed 95% reliability. At that time, none of the assessors worked at the Whittington.
3.1. Appropriateness of admission The results are shown in Table 1. There was a significant difference in the number of elderly admissions 94 (34% of admissions) in the control period compared to 104 (43% of admissions) in the study period (P=0.03). There was no significant difference in the number of inappropriate admissions in the elderly, ten (10.6%) in the control period and six (5.8%) in the study period (P= 0.2). Thus it appears that although there was a greater proportion of elderly admissions in the Christmas period there was no corresponding increase in inappropriateness.
3.2. Appropriateness of residence The results are shown in Table 2. The increase in inappropriate bed use in the elderly from 10 to 20% was statistically significant (P= 0.02). There was no difference in inappropriate bed use in the younger population. The patients who were deemed inappropriate were classified into various groups. These results are shown in Table 3.
4. Discussion The inappropriateness rates found in our study are similar to those in other studies using the AEP. The most comparable paper described 186 consecutive Table 1 Appropriateness evaluation protocol (AEP) results for admissions studied 75 years and younger
76 years and older
Control period Inappropriate Appropriate Total
8 (1)a 175 (29) 183 (30)
4.4%b 95.6% 100%
10 (4) 84 (20) 94 (24)
10.6% 89.4% 100%%
Study period Inappropriate Appropriate Total
6 (2) 130 (44) 136 (46)
4.4% 95.6% 100%
6 (1) 98 (30) 104 (31)
5.8% 94.2% 100%
a b
Numbers in parentheses are those admitted by investigators. Percentages are of the total for that age group and that time period.
D.J.E. Henshaw et al. / Arch. Gerontol. Geriatr. 31 (2000) 77–83
82
Table 2 Results of the appropriateness evaluation protocol (AEP) day of care criteria 75 years and younger
76 years and older
Control period Inappropriate Appropriate Total
9 104 113
8%a 92% 100%
11 99 110
10% 90% 100%
Study period Inappropriate Appropriate Total
8 88 96
8% 92% 100%
28 113 141
20% 80% 100%
a
Percentages are of the total for that age group and day.
Table 3 Patients who were found to be inappropriate for day of care. The table shows reasons for continued stay in hospitala
Awaiting assessment or discharge package home Awaiting placement in residential or nursing home Awaiting other speciality bed or opinion Discharge planned \3 days Other
Inappropriate 7 December 1996 (n =20)
Inappropriate 28 December 1996 (n =36)
7 (4)
11 (10)
7 (5)
7 (6)
3 (1) 0 3 (1)
9 (4) 3 (3) 6 (5)
a
The table shows reasons for continued stay in hospital. Number for patients 75 years old and over in parentheses.
elderly admissions in Portsmouth, UK (Tsang and Severs, 1995) that showed an inappropriateness rate of 11% on AEP. We concur with Tsang and Severs that 100% appropriateness is neither beneficial nor desirable as this would suggest that some patients who were appropriate for admission had been discharged home. Our study has shown that although there was an increased proportion of elderly admissions over the holiday period there was no increase in the proportion or numbers of inappropriate elderly admissions. The numbers of younger medical admissions over the Christmas period were less. This could reflect younger people travelling over the holiday period, reduced GP referrals, or random variation. The study suggests that there is not an increase in inappropriate admissions over the Christmas holiday period amongst the elderly. Previous studies (Houghton et al., 1996; Smith et al., 1997) in non-holiday periods have suggested that delayed discharge is more important than inappropriate admission. Our study suggests that there is a genuine increase in inappropriate bed use over the Christmas holiday period, and that this is largely accountable for by delays in planning and execution of discharge of the elderly over Christmas.
D.J.E. Henshaw et al. / Arch. Gerontol. Geriatr. 31 (2000) 77–83
83
Acknowledgements We would like to thank Prof. James Malone-Lee for his constructive criticism and thank the CREED department at the Whittington hospital for their help with data collection and analysis.
References Gertman, P.M., Restuccia, J.D., 1981. The appropriateness evaluation protocol: a technique for assessing unnecessary days of hospital care. Med. Care 19, 855 – 871. Houghton, A., Hopkins, A., 1996. Acute medical admissions: results of a national audit. J. R. Coll. Physicians Lond. 30, 551–559. Houghton, A., Bowling, A., Jones, I., Clarke, K., 1996. Appropriateness of admission and the last 24 hours of hospital care in medical wards in an east London teaching group hospital. Int. J. Qual. Health Care 8, 543–553. Liberati, A., Apolone, G., Lang, T., Lorenzo, S., 1995. A European project assessing the appropriateness of hospital utilization: background, objectives and preliminary results. The Project Steering Group and the Coordinating Center. Int. J. Qual. Health Care 7, 187 – 199. Murdoch, P.S., 1996. Out in the cold at Christmas. Hospital Doctor, 21. 1-1-1996. Random House Webster’s College Dictionary. 1996. Smith, H.E., Pryce, A., Carlisle, L., Jones, J.M., Scarpello, J., Pantin, C., 1997. Appropriateness of acute medical admissions and length of stay. J. R. Coll. Physicians Lond. 31, 527 – 532. Tanne, J.H., 1992. Granny dumping in the US [news]. Br. Med. F. 304, 333 – 334. Tsang, P., Severs, M.P., 1995. A study of appropriateness of acute geriatric admissions and an assessment of the Appropriateness Evaluation Protocol [see comments]. J. R. Coll. Physicians Lond. 29, 311–314.
.